The ultimate cause of the deaths of children in Gorakhpur was a communicable fiscal disease which is endemic all over India—obstructions in the flow of public funds. Photo: AP

There can be no doubt about the massive achievements of the Indian state between 1947 and 2017. Starting with the successful assimilation of millions of refugees from Pakistan and merger of princely territories into a single nation, there surely is cause for satisfaction at having survived intact up to the age of 70.

However, 70 is also a time for critical introspection, and as a focus for such self-examination, I shall pick up two (of several) tragedies that occurred in the anniversary month of August. This is not done in a spirit of self-flagellation, supposedly one of our national pastimes, but to unearth what we can learn from each about the structural reforms we have failed to do. The two events selected here are the child deaths in the Baba Raghav Das (BRD) Medical College Hospital in Gorakhpur which spiked twice during August, and the several episodes of sewage workers in Delhi dying on the job. There were train derailments which killed many more, but the reforms needed there are known. There was also a tragedy of a different kind—the upheaval in Haryana which killed people and destroyed public property.

The first reform focus I shall pick up was the death in early August of 30 children over a span of 48 hours (another spike is underway at the time of writing). The allegation that the cause was withdrawal of oxygen to children on life support was disputed by Uttar Pradesh health minister Siddharth Nath Singh, despite his own admission in an interview (Hindustan Times, 14 August) that the oxygen supplier, Pushpa Sales, had written to the BRD principal on 1 August demanding release of Rs68 lakh owed to them for past supplies. The BRD principal forwarded the Pushpa Sales complaint to the relevant state department in Lucknow on 4 August. A transfer of Rs2 crore is reported to have been released to BRD the very next day, but the actual payment to Pushpa Sales (and that too partial) happened only on 11 August, after they had acted on their threat to cut off supply.

Whatever malfeasance there might have been at various levels, the ultimate cause of the deaths of those children was a communicable fiscal disease which is endemic all over the country—to wit, obstructions in the flow of public funds. The BRD Hospital case was by no means unusual. Speak to anyone in the corporate sector, the small-scale sector, any discom, and they will tell you that getting payments out of a government department is a nightmare. This problem might actually be worse today than it was 70 years ago, and has probably become worse still after 2003, when governments at the Centre and states all enacted fiscal responsibility legislation. The tragic paradox is that these laws became interpreted in a narrow sense of control on fiscal deficits and lost the larger plot of fiscal responsibility. A payment delayed to the next year makes the deficit look smaller this year.

Some segments of the delay can be pinned on the college, but the central culprit for the mounting arrears to the oxygen supplier was the relevant department in Lucknow. It is possible, even probable, that the obstruction to fund transmission from Lucknow was because of suspicion of diversion of supplies at the hospital, but surely the response by the relevant department should have been to put in place routine audit systems at the hospital. The payment and concurrent audit systems of state governments remain seriously unreformed, a problem across all political colours. The statutory transfers owed by the Centre to states in accordance with Finance Commission provisions flow as they accrue, and therefore cannot be faulted as the source delay for any of this. They are routinely transmitted. This is probably the major feature of our functioning that has held us together for 70 years.

Although not all problems with fiscal plumbing result in such a gargantuan tragedy, there are smaller tragedies that happen every day—the elderly starving from non-receipt of old age pensions; students dropping out for non-receipt of scholarships. The list is long. Local governments follow the example set by higher level governments. After the lavish grants to them started with financial year 2015-16 as recommended by the Fourteenth Finance Commission, some states like Karnataka most commendably sequestered a portion of the grants for payment of unpaid arrears and current dues to water and electricity supplying utilities. Blocked intra-governmental transfers play a key role in public service delivery being as bad as it is.

Arrears in receipts from public sector customers have played an important part in the run-up of defaults in payments by power distribution utilities to the banking system. The same cause which affected oxygen supply to a hospital is contributing to the banking crisis in the country. Although not a parameter in ease of doing business surveys, it would feature in the investment plans of any company which sells its products exclusively or largely to the public sector. It is thus among the structural underpinnings of our current macroeconomic malaise. Time-bound concurrent audit and payments systems will do the trick. It can be done one department at a time. Accrual accounting in place of cash accounting will do it too, but calls for more radical system-wide reform.

Acute encephalitis syndrome (AES) is a fairly recent scourge. There does not presently exist a vaccine for AES, nor even a protocol to fight the disease. A research paper (in a 2013 issue of the International Journal Of Current Microbiology And Applied Sciences) mentions 1973 as the year of the first recorded outbreak in north Bihar. It has grown steadily in incidence since then to what has become an annual post-monsoon epidemic. Any seasonal affliction is predictable. A war-room in the health department of the state administration in Lucknow could have been in daily touch during the monsoon months with the district panchayats in the afflicted districts, who could have reported on the new cases in each of the taluks under their supervision. The taluk panchayats in turn could have served as points of assembly of information from the gram panchayats falling within their respective jurisdictions.

But the panchayat structure in the country is not functioning in this manner at all. They are not connected in a web with one another. There is no evidence whatsoever that they have become an active partner with state governments in public health campaigns of the kind needed to prevent or at least understand the correlates of the regional pattern of killer diseases. We seem to have a structural inability to delegate, authorize and partner across levels of government towards a common purpose.

In the midst of this sense of collective failure, there was one piece of good news. The vaccine recently developed for another variant named Japanese encephalitis, according to one estimate, was administered to nine million children in 38 districts of UP this season. It did not eliminate the disease, but must certainly has brought down its incidence.

The BRD Hospital caters to a very large catchment area going beyond eastern UP to Bihar and even bordering areas of Nepal, receiving (according to the UP health minister) 4,000-5,000 cases per day in the peak month of August. As a passive recipient of cases from a failed preventive public health mechanism, it alone cannot be blamed for the high death rate from AES. There are allegations that hospital doctors diverted expensive inputs to their private clinics, but an effective concurrent audit system to check this can only be instituted by the relevant department at Lucknow.

The second tragedy I shall pick up was the sequence of deaths in August among sewage repairmen in the National Capital Region. This is a monsoon affliction again—the blockage of sewage lines. The worst of the four incidents were the death of three sanitation workers working for the Delhi Jal Board in Lajpat Nagar, and a later episode at Lok Nayak Hospital, where one died and two others were grievously injured (but survived probably because a hospital was near at hand). The two other incidents before and after were in sewage tanks in private malls. One can understand a private mall trying to pinch pennies, but what of a major public hospital or the Delhi Jal Board? What is our understanding of governance, that we will permit workers without safety masks to protect them from the life-threatening noxious gases coming out of a sewage manhole?

We are signatories to the International Labour Organization labour safety standards. There is a Prohibition of Employment as Manual Scavengers and their Rehabilitation Act of 2013, under which safety equipment is mandated for the protection of sanitation workers. Like much in the law, we merely ignored it. We continued to let sewage work be done in a manner which destroys the lives and health of the people doing it, even though by unblocking sewage lines, they were the ones who enabled us to live with dignity. They have been dying of the work all these decades, the only difference is this time they died on the job.

The good news is that the Delhi lieutenant governor ordered a total switch to mechanized cleaning of sewers on 21 August. This day should be honoured as a true day of liberation for our most oppressed workers. Here is one instance where a switch to mechanization is cause for celebration.

The battle is by no means won. Fiscal obstructions will delay installation. Until then, manual cleaning will have to be done, but hopefully with safety equipment. Once the machines are in place, it will only be a question of time before they become inoperable, unless maintenance grants are received on time. Unless that fiscal disease is fixed, we will have no option but to go back to manual cleaning of sewers once again.